Hepatitis C (cont.)

Mary D. Nettleman, MD, MS, MACP

Mary D. Nettleman, MD, MS, MACP is the Chair of the Department of Medicine at Michigan State University. She is a graduate of Vanderbilt Medical School, and completed her residency in Internal Medicine and a fellowship in Infectious Diseases at Indiana University.

Jay W. Marks, MD

Jay W. Marks, MD, is a board-certified internist and gastroenterologist. He graduated from Yale University School of Medicine and trained in internal medicine and gastroenterology at UCLA/Cedars-Sinai Medical Center in Los Angeles.

Who should receive antiviral therapy for hepatitis C virus infection?

Current treatment options are imperfect (see below). Patients with HCV infection should discuss treatment options with a physician who is experienced in treating the disease. Treatment is recommended in patients at increased risk for cirrhosis unless there are reasons that would make treatment unsafe. According to the National Institutes of Health (NIH) persons at increased risk for cirrhosis would include those with HCV infection and:

Persistent elevation of ALT (alanine aminotransferase, a liver enzyme in the blood)

High levels of HCV RNA in the blood

Evidence of early fibrosis (scarring) or moderate inflammation and injury of liver cells on liver biopsy

The NIH also recommends treatment for patients who are co-infected with HCV and HIV, because these patients have a more rapid course of liver injury.

These are general guidelines. Patients and providers may decide that treatment is needed for other reasons. For example, HCV infection may cause cryoglobulinemia. (See above.) Persistent cryoglobulinemia may be a reason for treating hepatitis C. Newer therapies may be offered to selected patients in research settings.

Individuals who should not be treated with antiviral therapy include those who are unable to comply with the treatment schedule, have reasons that may make treatment unsafe (for example,
allergy to the medications), have received a solid organ transplant, are pregnant or unwilling to practice adequate contraception during treatment, or who have reversible serious untreated conditions such as unstable
heart disease, uncontrolled
high blood pressure, or untreated major
depression.

Patients with unstable (decompensated) cirrhosis are
at high risk for complications for treatment and usually do not receive medical
treatment except in research settings. Fundamentally, the decision regarding
antiviral therapy in chronic HCV infection should be tailored to the individual
patient with careful consideration of the risks and benefits.

All patients with HCV should be vaccinated against
hepatitis B and hepatitis
A. They also should be counseled on measures to prevent the spread of HCV and
eliminating alcohol use. Finally, risk behaviors for HCV overlap with those of
HIV, and all patients with HCV should be tested for HIV.